Healthy Smiles” in Brent - A Supervised Tooth brushing Programme in children’s early years settings

Brent local authority commissions the delivery of an evidence-based oral health plan to improve child oral health and reduce inequalities, prioritising families with children under 5. this case study forms part of our children's oral health resource

The plan focuses on both universal brief oral health advice by trained health and social care professionals together with the distribution of toothpaste and brush packs both at child progress checks and opportunistically at touch points and the targeted delivery of a supervised toothbrushing programme for 2-5 year olds. To date, this rolling programme has been offered to children attending 33 nurseries and primary schools within Harlesden, an area of highest need.

The challenge

Brent has historically had high levels of poor oral health among children. There are huge inequalities in oral health with tooth decay being strongly associated with deprivation and social exclusion. This, and the fact that tooth decay is largely preventable, made it a priority locally. The National Dental epidemiology survey (2015) shows over 31 per cent of Brent five year olds had experience of decay, compared with 27 per cent in London and 24 per cent in England. Although this was an improvement compared to the 2012 results, Brent still has a considerably higher rate of 5 year olds with decayed teeth, compared to the London and England rates and wide inequalities within the borough. To address the level of disease and persistent inequalities there needs to be action at scale, but recognising within limited resources both a universal and targeted approach was required.

Raising awareness and engaging schools and nurseries was initially seen as a challenge, but this was addressed by organising a launch event in the local library. The majority of schools and nurseries attended along with Public Health England, the lead councillor, the provider, library services, local residents and Public Health Brent. Alongside the launch oral health is embedded within the Making Every Contact Count and the Healthy Child programmes across health and social care and at a strategic level together with the Starting Well NHS England programme to promote early access for prevention. 

The solution

By introducing the Supervised Toothbrushing Programme it is anticipated that this will enable children and parents to establish good brushing behaviours and will also encourage parents to register their children at the dentist early for prevention. This programme will hopefully encourage positive oral health behaviour to be embedded into their normal routine so they will continue with this process for the rest of their life, therefore preventing tooth decay, pain and sepsis, which can lead to hospital admissions.

The impact 

It is too early to show evidence that this has made a difference. The PHE Return on Investment tool indicates that after 5-6 years of offering this programme and the wider work including that of NHS England London that the programme will break even.

At five years, it is estimated that 684 days at school will be saved, with 280 days at work gained for the carer with £24,398 savings in the local economy due to days gained at work. Gross cost savings to the NHS due to averted dental treatment at five years are estimated to be £106,768.

How is the new approach being sustained

Public health is funding the scheme with training and resources being provided throughout the year.

A new 0-19 years children’s public health contract has been procured which started on 1st June 2017. The specification includes a requirement for all staff to be trained to offer advice to children and families on oral health using the ‘Lift the lip’ approach.

Given the limited specialist resource for oral health promotion (OHP) available, there is a focus on training the trainer approaches with the OHP service being commissioned to train front line health, early help, early years, library and education staff.

Public Health has worked with HealthWatch Brent in designing a survey on oral health. The survey took place in February 2018 and the aim was to find out from parents what the barriers are for registering with a dentist, and are they brushing their child’s teeth twice a day etc. The results have not yet been finalised.

The Public Health team have developed an approach for Council and health front line staff Making Every Contact Count. This is designed to capture and make use of opportunities for front line staff from all services to bring public health approaches, information, advice and signposting to their routine contacts with residents.

The Healthy Early Years (HEY) award scheme has been running in Brent since 2013 during which time 104 awards (including 12 renewals of awards) have been made to nurseries, childminders and children’s centres who have demonstrated action to ensure every child has the best start in life by:

  • focusing on the most important years of a child’s life
  • encouraging behavioural changes that will have a positive effect
  • ensuring the longer term health and wellbeing of a child’s life
  • giving the best advice and information to parents to help support them

Oral health is one of the priority areas for action and the 2015/16 evaluation of the HEY awards showed a 19% increase in the number of children that had been to the dentist in the last 6 months from baseline.

The Local Authority Public Health team have developed a core offer package to schools, providing support and training in nutrition and healthy eating, oral health, mental health, physical activity and drugs and alcohol to help improve pupils’ health and achievement. The core offer will also assist schools in achieving the Healthy Schools London bronze, silver and gold awards.

Lessons learned

Having a Brent Child Oral Health Steering group, chaired by a Public Health England (PHE) Consultant from the start has been key to successful multi-agency partnership working, brokering and enabling ‘buy in’ from partners within and across the local authority at the strategic and operational level 

Looking at the joint strategic needs assessment and identifying the area of highest need to focus on the intervention was a useful exercise. This has ensured resources were not diluted. Once a few settings became engaged there was a ripple effect with others requesting to join. Now that the programme has been established in one locality, it is to be extended to another area of high need.

The following is an abstract from a member of staff:

Jenny’s Story at Kids First Nursery                                   

Participant of Healthy Smiles tooth brushing programme: Jenny Lewis –Carnegie- Oral Health Champion (Kids first Nursery)

During the launch, Jenny Lewis, from Kids First Nursery commented at her delight about the programme.

My experience from before seeing decayed teeth, I wanted help for a long time but I didn’t know how or where to get help. I went to the Early Years Conference and enquired if there was anything available but I didn’t get much joy, until July when Sapna (from the oral health team) called and it made my day! I jumped at the chance and said a big “yes”.

The children were fascinated with the dental talk that Sapna did with them as she approached them really well and kept them engaged.

It was hard to think and imagine how am I going to supervise 20 children brushing their teeth at the staff training stage, but when Sapna did the practical session it became very easy and we could fit in with our daily routine after the children finished eating and they then brushed their teeth.

If the staff hadn’t set up straight away the child would remind them that “we haven’t brushed our teeth”

It has increased the children’s CL (Communication and Language.), PSED (personal, social, and emotional development) and child’s independence. The children’s numeracy and social skills have increased also.

Early intervention is very important so children don’t suffer dental pain, swelling, losing teeth very early, and not having a beautiful smile, decreased confidence and a lot of other problems that affects the child’s wellbeing.

We have 20 consented children brushing every day at our setting now. The long term effect of this will eliminate children being admitted in the hospital due to dental pain and reduce dental decay in children too.

Educating parents and carers will help them to change their mind-set to tooth brushing being an essential part of life! They can make brushing time fun if they talk and explain to the children the importance of healthy teeth and healthy smile


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